Ethicists question planned order of bird flu shots

At the heart of the debate is whether to focus on the number of lives or 'life-years'

CECI CONNOLLY, Washington Post

Published 5:30 am, Sunday, May 14, 2006

WASHINGTON - On the Titanic, it was women and children first. During a syphilis outbreak in World War II, soldiers with the best chance of recovery were the ones to get precious doses of penicillin.

In the event of a global flu pandemic, federal officials have said they intend to give vaccine first to health-care workers, followed by the oldest, sickest patients — a policy aimed at saving the most lives. But one of the government's top medical ethicists is challenging that approach, arguing it is more appropriate to give young adults priority because they are at higher risk of dying in a flu pandemic and still have many productive years left.

"Most people have the intuition to say, 'Give it to my 19-year-old. I got to 65; I've lived a good life,' " said Ezekiel Emanuel, of the bioethics department at the National Institutes of Health. "We are not interested in purely the number of lives (saved), but also life-years."

As the government prepares for a potential pandemic influenza outbreak, one of the thorniest questions to arise is who should be first in line for limited supplies of antiviral medicine and vaccine.

Experts fear that the avian influenza that has raged through birds in Asia could trigger a pandemic if it gains the ability to move easily from human to human, with the potential to kill 210,000 to 1.9 million Americans.

There is no debate that vaccine makers and medical personnel should be first to be immunized, because they will then be able to save many more lives. But deciding who follows is not an easy call, said Jon Abramson, chair of pediatrics at Wake Forest University School of Medicine and chair of one of two federal advisory panels that helped develop the current policy.

Some panel members argued that children should be the top priority, he said. "If you save a child who is 2, you've potentially saved 80 quality years," he explained. "If you save a 65-year-old, you may have only saved 15 years of quality life."

Already federal agencies are sparring over who is "critical," posing no-win dilemmas such as: air traffic controllers or border patrol officers? Meanwhile, state leaders and private corporations are scrambling to build their own stockpiles of antiviral medication, fearful the federal government will not deliver.

Nevertheless, the two advisory panels unanimously recommended ranking the elderly ahead of other sick or healthy individuals because they believe senior citizens "are at high risk of hospitalization and death."

One of the guiding principles in the deliberations was "equity," Abramson said. "They strongly felt you cannot prioritize on the basis of age or gender or race."

But in the 1918 pandemic, Emanuel said, "the people who died were young, healthy 20-year-olds." If the next pandemic resembles that outbreak, as some scientists suggest, "and you immunize the elderly, then you will have hundreds of thousands of deaths of people in their twenties."

Emanuel and co-author Alan Wertheimer, writing in Friday's issue of the journal Science, spell out an alternative ranking, with medical workers first and young adults next, followed by people ages 41 to 50 and finally those 51 and older.

"Children under 13 could be confined to home instead of receiving a vaccine," they wrote. "Within this framework, 20-year-olds are valued more than 1-year-olds because the older individuals have more developed interests, hopes and plans but have not had an opportunity to realize them."

Within each tier, the two suggest, there should be sub-rankings for "critical" workers, such as firefighters and food delivery personnel.

Because it will take as long as six months after an outbreak begins to produce an effective vaccine, Abramson said, it will be possible to adjust the policy as scientists learn more about the virus, who is most vulnerable and what strategies appear most successful. "If, in the first month, we see it is mainly 20-year-olds that are dying, we'll reprioritize," he said. "This is not written in stone."

Neither the federal advisory panels nor Emanuel and Wertheimer waded into the issue of whether to share vaccine with other countries. "This raises fundamental issues of global rationing that are far too complex to address here," concludes the article in Science.